Journal Article > Study

Surgeon technical skill, real-time problem solving, and communication quality are essential for avoiding harm during surgery. This study found that those types of human errors were responsible for 51.6% of 188 surgical adverse events at 3 hospitals. A past PSNet perspective delineates the evolution of surgical patient safety.

Journal Article > Study

The authors describe the results of a survey of anesthesiology chiefs designed to understand their perceptions of the Veterans Health Administration efforts surrounding the lessons learned process for adverse events occurring in anesthesia. Of participants who had been aware of lessons learned, 90% shared them with staff and 75% described changing or reinforcing safety behaviors.

Journal Article > Study

This cross-sectional study examined outcomes for Medicare patients undergoing complex cancer surgery at U.S. News and World Report top-ranked cancer hospitals and their affiliates. Investigators found that surgery performed at affiliated hospitals was associated with higher 90-day mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the study. The authors suggest that while affiliated hospitals may share branding with top-ranked cancer facilities, further study of such networks is necessary to inform care for cancer patients.

Press Release/Announcement

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

Little is known whether the relationship between safety data and patient experience data can inform opportunities for improving care. In this retrospective study, researchers used data on complications and safety incidents as well as patient-reported events and experiences for 4236 hospitalized surgical patients at a single academic medical center to understand the relationships between these sources of information. They found that patient-reported issues were associated with the presence of complications or safety events among patients with nonpositive (neutral or negative) experiences, but not among those with positive experiences. Patients who experienced complications or safety events but did not identify problems with their care demonstrated a decreased risk of a nonpositive experience compared with patients who experienced no complications or safety events and did not report issues. The authors conclude that using data in this manner can help inform opportunities for improving care and that health care professionals can optimize the patient experience even when complications and safety events happen. A past PSNet perspective highlighted the experience of a health care professional as a patient.

Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.

Journal Article > Study

Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

This study examined the implementation of a tool integrated into the electronic health record to export surgical discharge data to an adverse event reporting platform. The tool demonstrated high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than traditional reporting mechanisms. The authors recommend implementation of these automated reporting mechanisms.

Journal Article > Study

Clinical decision-making is a complex process affected by many factors and has important implications for patient outcomes. Using data from the Australian and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be concerning by reviewers. The most frequently noted incident was decision to operate, followed by diagnostic error and insufficient postoperative evaluation. The authors suggest that thorough discussion of complex cases in advance of surgery might mitigate CDMIs related to decisions to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes for reviewing and learning from surgical mortality. A WebM&M commentary discussed an incident involving a diagnostic error in which a patient was taken to the operating room for an unnecessary surgery.

Newspaper/Magazine Article

Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.

Journal Article > Study

Overlapping surgery is a controversial practice in which an attending surgeon performs more than one procedure concurrently. This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found no differences between complication rates for overlapping versus nonoverlapping procedures. The authors recommend individualizing decisions regarding overlapping surgeries.

Journal Article > Commentary

Patients who experience care complications are vulnerable to psychological consequences that can affect their relationship with their clinical teams. This commentary relates insights from a patient who experienced complications resulting from care, the negative impact on her relationship with her surgeon, and how she felt when her surgeon expressed empathy. The author offers recommendations for clinicians to demonstrate their concern and improve practice when problems occur.

Journal Article > Study

Prior work has demonstrated that surgical outcomes differ depending on individual practitioner skill, and concerns have been raised regarding the need to assess skills of aging physicians. This study examined whether cataract surgery outcomes differ for late-career ophthalmologists, defined as those who completed medical school at least 25 years ago, compared to mid-career ophthalmologists, who completed medical school 15 to 25 years ago. This secondary data analysis of all single-eye cataract surgeries performed in Ontario between 2009 and 2013 found that almost 30% of procedures were performed by late-career practitioners. Overall, adverse surgical events did not differ by career stage, although very small increases in risk of two specific complications—dropped lens fragment and endophthalmitis, a surgical site infection—were observed. These results suggest that cataract surgery by late-career ophthalmologists does not pose a high-priority safety hazard.

Newspaper/Magazine Article

This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.

Journal Article > Study

Physicians who receive more patient complaints about communication and behavior are more likely to face malpractice claims. This study examined whether results from surgeons' 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were associated with risk of malpractice claims. Surgeons with worse performance for attentiveness, informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons in the highest 10% for the negative behaviors of snapping at or talking down to others also were more likely to have malpractice claims. These results echo prior studies of physician behavior and malpractice risk. The authors suggest that addressing negative behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety surveillance.